Experiences of acquired brain injury one-month post-discharge from acute hospitalisation

Background Healthcare professionals may have a preconceived idea about life after an acquired brain injury (ABI). Understanding lived experiences of individuals with ABI and their significant others, post-hospitalisation, may improve communication between healthcare professionals and individuals directly influenced by the ABI. Objective To describe perceived experiences of individuals with ABI, and their significant others, regarding rehabilitation services and returning to daily activities, one-month post-discharge from acute hospitalisation. Method Semi-structured interviews, via an online platform, expanded on the experiences of six dyads (individuals with an ABI and their significant others). Data were thematically analysed. Results Six main themes emerged that best described participants’ experiences; two of which were shared between individuals with ABI and their significant others (SO). Individuals with an ABI acknowledged recovery as their priority and highlighted the importance of patience. The need for counselling and additional support from healthcare professionals and peers arose. The SO expressed a need for written information, improved communication from healthcare professionals, and education regarding the implications of an ABI. The coronavirus disease 2019 (COVID-19) pandemic negatively influenced all participants’ overall experiences, mainly because of termination of visiting hours. Psychosocial intervention would have been beneficial to all participants. Faith influenced most participants’ attitudes towards recovery and adapting post-ABI. Conclusion Most participants accepted their new reality but required additional support to cope emotionally. Individuals with an ABI would benefit from opportunities to share experiences with and learn from others in a similar situation. Streamlined services and improved communication may alleviate anxiety among families during this crucial transitional period. Contribution This article provides valuable information on the perspectives and experiences of individuals with ABI and their significant others during the transition from acute hospitalisation. The findings can assist with the continuity of care, integrative health and supportive strategies during the transition period post-ABI.


Introduction
(SO), such as a family member, close relative or caregiver, who cares for the individual with an ABI is unprepared and often feels ill-equipped to meet the resultant changes that occur in their loved one after an ABI (Degeneffe 2015;Whitehead & Baalbergen 2019).
Individuals with ABI are likely to experience difficulties in all areas of the ICF, especially interaction between themselves and their environment (Kusambiza-Kiingi, Maleka & Ntsiea 2017;Ntsiea 2019). Difficulties seen during the early phase of recovery may include loss of memory, loss of physical functioning and difficulty verbally communicating, hindering active participation in daily activities (Kusambiza Kiingi et al. 2017;Stiekema et al. 2020). Experiences within the first week until the first month post-ABI are critical because of the transition periods from hospitalisation, rehabilitation, and reintegration into the community (Ntsiea 2019). This includes access to information regarding education about an ABI, caregiver education and discharge readiness before discharge from acute care and during the ongoing rehabilitation process (Piccenna et al. 2016;Stiekema et al. 2020).
Providing information to individuals with ABI and their family is important; however, communication between healthcare professionals (HCP) and family members has been recorded as 'inadequate', resulting in poor understanding and implementation of health information (Soeker & Ganie 2019). In cases where SOs have received information about an ABI, they report pamphlets as difficult to understand and are hesitant to ask for further explanations (Li et al. 2020;Webster et al. 2015). There is a significant need for HCP to better understand the social context of individuals with ABI while in the acute care setting and during the transition to their home environment with their SO (Legg & Penn 2013).
Individuals with ABI experience a loss of 'pre-injury self' which may involve a loss of independence, and loss of roles within the household (Chembeni & Nkomo 2017;WHO 2018). Upon discharge, individuals with ABI are likely to have inadequate activity and participation in their home and community because of physical or emotional limitations (Kusambiza-Kiingi et al. 2017). Complex emotions are often exacerbated as families can find it difficult to accept a new reality (Abrahamson et al. 2017;Piccenna et al. 2016;Villa, Causer & Riley 2020). Loss of friendships are likely to be experienced upon returning home as individuals with ABI express difficulty communicating with others (Chembeni & Nkomo 2017). This often leads to avoidance of familiar activities despite the need to participate within the home and community (Villa et al. 2020;Webster et al. 2015).
Social disconnect is another common experience as individuals with ABI may feel a loss of social status and experience limitations within their community (Soeker & Ganie 2019;Villa et al. 2020). Strain can be worsened in families when the ABI leads to communication difficulties (Ntsiea 2019). Families are often the most important support system while individuals with ABI recover and develop a new sense of self, reintegrating into home and community settings (Chembeni & Nkomo 2017;Villa et al. 2020;Webster et al. 2015). Understanding the lived experiences and emotional well-being in relation to the impact an ABI has on the individual and their SO has been continuously highlighted in research (Andersson et al. 2016;Harvey 2018).
The need for quality information, communication and collaboration are emphasised as factors that reportedly would have improved an individual's overall experience post-ABI (Andersson et al. 2016;Harvey 2018).
Experiences within the first month post-ABI are important because of various stages of rehabilitation to reintegration into communities (Abrahamson et al. 2017;Ntsiea 2019). Two of the highest-ranked needs during hospitalisation involve clear explanations of the ABI and discussing realistic outcomes about recovery (Mauss-Clum & Ryan 1981). These needs continue to align with recent findings where individuals with ABI and SOs experience similar difficulties regarding the impact an ABI has on a family unit (Chembeni & Nkomo 2017;Holloway, Orr & Clark-Wilson 2019;Villa et al. 2020).
The average stay in a South African tertiary level hospital is 6 days, and individuals with ABI are often discharged home too soon (Kusambiza Kiingi et al. 2017;Mudzi et al. 2012). Not all South Africans are covered by private medical schemes and therefore do not have easy access to rehabilitation facilities (Joosub 2019). In the public sector, few individuals with ABI benefit from post-acute rehabilitation because of an overburdened healthcare system and inadequate number of HCP to manage this caseload, limiting opportunities for them to access, adapt and learn about their recently acquired brain injury (Abrahamson et al. 2017;Joosub 2019;Taylor & Ntusi 2019). Transitioning into a home environment following ABI in an upper-middle income country, such as South Africa, has not been explored and further research is warranted.
Recent studies show that SOs experience emotional and physical strain while caring for individuals with ABI (Abrahamson et al. 2017, Webster et al. 2015. Additionally, SOs often experience a lack of support from family members, likely exacerbating feelings of uncertainty, loneliness, and increased burden of care (Chembeni & Nkomo 2017;Webster et al. 2015.) Education and necessary referrals, while in acute care, may support SOs of individuals with ABI during the transition period (Harvey 2018;Holloway et al. 2019).
Previous studies from upper-middle income countries found communities and HCP may benefit from addressing the loss of emotional and physical independence post ABI (Bellon et al. 2015;Legg & Penn 2013). Home-based services are available in such cases, but referral pathways and implementation are not always adequate (Ntsiea 2019). In addition to home-based services, all families should have adequate access to information before discharge from acute care and while considering ongoing rehabilitation needs http://www.ajod.org Open Access (Picenna et al. 2016). Another challenge within the public sector is premature discharge of individuals with ABI without adequate information about their recovery or available resources (Liang et al. 2017). This may result in complete dependence on family members (Ntsiea 2019). Research of this nature, conducted qualitatively, has proven the importance of examining experiences post-ABI (Abrahamson et al. 2017;Masuku, Mophosho & Tshabalala 2018;Souchon et al. 2020).
There are currently a few studies that focus on the transitioning periods from acute care to the community setting in upper-middle income countries, with low-income settings, such as South Africa (Kusambiza-Kiingi et al. 2017;Walker, Schlebusch & Gaede 2021;Webster et al. 2015). It is important that HCP base their decisions on real needs that are relative to the setting. Focusing on the current lived experiences of individuals with ABI and their SOs may highlight the importance of person-centered care and allow an easier transition to an adjusted way of living in future scenarios (Andersson et al. 2016;Harvey 2018). The aim of this study was to describe perceived experiences of individuals with ABI, and their SOs one-month postdischarge from acute hospitalisation.

Research methods and design
The study aimed to achieve a deeper understanding of the direct perceptions or daily experiences of individuals with an ABI and their SO (Leedy & Ormrod 2015). Describing individuals' experiences tied in with the theory of realism, which claims there can be different realities that exist based on the same situation, its meaning, and interpretations held by people (Creswell et al. 2016;Rahman 2017). Individuals' contexts and experiences may influence their perceptions and beliefs (Maxwell 2012;Rahman 2017). This theory was appropriate for this study as it allowed for a better understanding of the relationship between individuals' perspectives and their actual situations (Leedy & Ormrod 2015;Maxwell 2012).

Research design and data collection
The twelve participants of this study were identified in two private, acute care facilities through the referral of the private Speech-Language Therapist (SLT) practice where the first author (K.T.) was employed. These two hospitals are in a South African city and offer services to outlying, smaller communities who do not have access to private hospitals in their hometowns.
Participants were interviewed one-month post-discharge from acute hospitalisation, focusing on experiences during hospitalisation and post-discharge. Informed consent was obtained by the first author (K.T.) during acute admission. Where this was not possible, the author emailed the necessary documents to the treating SLT at the rehabilitation facility. Two SOs who did not live nearby were also emailed consent and demographic forms for completion.
Purposive sampling was used to recruit six dyads of participants from each acute care facility (Leedy & Ormrod 2015). The first author made use of videoconferencing via WhatsApp video call as the primary medium to conduct a once-off semi-structured interview. The interview schedule adapted from Abrahamson and colleagues (2017)

Participants
Participants were only included once a diagnostic CT (computerised tomography) or MRI (magnetic resonance imagery) scan confirmed the presence of a single ABI and subsequent referral to SLT services during acute hospitalisation. Upon administering the Cognitive-Linguistic Quick Test (CLQT) as a routine assessment, individuals with ABI who scored between 2.5 -4.0 on their overall composite severity rating (CSR) and 'mild' or 'within normal limits' on their language abilities, were considered for inclusion (Box 1). All participants had to be older than 18 years and have conversational English. Once the individual with ABI was invited to participate, their nominated SO was also invited to take part, forming a dyad. The SOs were only included if they were primarily responsible for caring for, and lived with or near, the individual with ABI (Box 2). Participants were recruited between February and July 2021. A pilot study was conducted with one dyad, but these data were not included in the final sample because of changes that were made to the interview schedule subsequent to the pilot study.
The six participants with ABI were aged between 19-57 years old, and the SOs were 42-48 years of age. Five participants were male and seven were female (Table 1). The six SOs were directly related to the individuals with ABI and had familial roles of daughter, wife, husband, mother and sister. The youngest participant was a student who could not continue with her studies, and one participant opted for early retirement, aged 47 years old. As a result of their ABI, the remaining four participants required assistance returning to work. Ten participants were permanently employed. In addition to the SOs' own employment, there were demands to assist in running their family members' business post-ABI. Table 1 further elaborates on participants' employment. Participants' home languages included Afrikaans, Northern Sotho, and Southern Sotho. None of the participants spoke English as their primary home-language but used it conversationally. Interview questions were therefore repeated when necessary, simplified to use layman's terms and the first author translated to obtain the appropriate English word from Afrikaans participants, when asked. None of the individuals with ABI could return to driving after their injuries.

Data analysis
Data were analysed using inductive thematic analysis to allow for data to be coded without placing results into a preexisting coding framework (Braun & Clarke 2013). Thematic analysis aimed to examine participants' experiences and perspectives in a direct manner, without assuming any other underlying meanings (Braun & Clarke 2013;Leedy & Ormrod 2015).
The first author read through and manually corrected the transcriptions against the audio recordings. Thematic analysis followed steps outlined by Braun and Clarke (2013). The first author initially read through the transcripts to identify common experiences, which was a key phase when interpreting the qualitative data set (Bird 2005). Experiences focused on preparation for discharge, services received during admission, adapting from acute care and transitioning back to social and home environments, one-month post-discharge from acute hospitalisation. The second phase involved using Atlas.ti 9 software (Scientific Software Development GmbH 2020) to establish codes and subsequently highlight similarities and differences between the data sets of individuals with ABI and their SOs (Braun & Clarke 2013). The common experiences were highlighted and grouped together.
Through revisiting the raw data and debriefing with coauthors, consensus on themes was reached in phase three (Braun & Clarke 2013;Elliot 2018). Sub-themes were created BOX 2: Inclusion and exclusion criteria for SO of the individual with an ABI.

Inclusion criteria
• Participant was a partner, carer, family member or friend of the person with the ABI (Hatteberg 2020), • SO lived with, or was in a position to visit regularly (at least twice a week) with the person with the ABI, • SO had an ongoing relationship with person with an ABI, • Participant provided direct care to the person with an ABI (e.g., bought their groceries or took them to their appointments), • Participants were aged 18 years and older, • Participants used English as one of their more dominant languages, using it with ease. (Kiran & Gray 2018) • Participants had access to a smartphone device with the WhatsApp mobile application, or alternatively Zoom Exclusion criteria • Participants were excluded if the person with the ABI did not consider the person as their significant other, • Participants were excluded if they were not directly involved in caring for the individual with ABI.
ABI, acquired brain injury; SO, significant other.

BOX 1:
Inclusion and exclusion criteria for participants with an ABI.

Inclusion criteria
• Presence of a single ABI, confirmed by a medical report or results of a CT and/or MRI scan, interpreted by the radiologist, • Participant was aged 18 years and older, • Participant was referred to the SLT during acute hospital admission for treatment, • Participants used English as one of their more dominant languages, or using it with ease (Kiran & Gray 2018) • Participants who could provide verbal or written consent, • Participant could participate in verbal conversation, express basic needs, and produce short sentences (Abrahamson et al. 2017). This was established by the treating SLT • Participants' CSR for their cognitive abilities fell between the ranges of 2.5-4.0 on the CLQT. The translated scores indicated cognitive abilities 'within normal limits' (WNL) or 'mild', • Participants' SR for their language abilities fell within the ranges of 'mild' to 'WNL' on the CLQT, • Participants fell within the time period of one-month postdischarge from an acute hospital setting, • Participants had access to a smartphone with the WhatsApp application downloaded, or alternatively Zoom.

Exclusion criteria
• Participants were excluded if they had severe communication and/ or cognitive impairments. This was based on whether the person with the ABI was able to engage in meaningful conversation or if there were concerns about their capacity to provide consent, • Participants who had co-occurring diagnoses such as dementia or Alzheimer's disease, that may influence results, were not asked to participate.
where similar ideas could be grouped and discussed together. Discussion among the three authors contributed to credibility of the data and provided alternative suggestions where necessary (Connelly 2016; Leedy & Ormrod 2015). This ensured that the interpretation and development of themes reflected the participants' personal experiences and related to the aim of the study.

Ethical considerations
Ethical clearance to conduct this study was obtained from the University of Pretoria Faculty of Humanities Research Ethics Committee (No. HUM039/0920).

Results
Six main themes were agreed upon after analysing the personal experiences of the individuals with ABI as well as their respective SOs (Figure 1). Between the two groups, two themes were shared. One of the shared themes developed three sub-themes. Fictitious names were used for participants and hospitals.
Interviews took place during the COVID-19 pandemic, exacerbating existing stresses surrounding the onset of an ABI. The pandemic negatively influenced all participants' well-being because of the changes in hospital regulations and protocols. All dyads commented on the difficulties coping while not being able to visit family and see familiar faces regularly within the hospital and rehabilitation settings. The resultant themes discussed are thus reflective of the circumstances surrounding the COVID-19 pandemic.

Shared themes to both individuals with acquired brain injuries and their significant others Everything has changed
The first shared theme discusses experiences of the individuals with ABI adapting to a new reality, losing independence, and as a result, their SOs now taking on the role of caregiver. All individuals with ABI acknowledged changes to their physical abilities and anticipated changes to participation in everyday activities. P04 stated: "My whole life is going to change when I'm going back home." Although the mentioned consequences of the ABIs were mainly physical, emotional consequences were also perceived. These difficulties directly influenced their experience within the workplace (P01) and progress within the rehabilitation hospital (P03). Most individuals with ABI expressed feelings of physical and cognitive fatigue, which was new to them.

Gratitude and support
Although the change post-injury brings challenges, individuals with ABI expressed appreciation for what they could do prior to the injury and to have survived. P03 was grateful for the opportunity to share with other patients and learn from their experiences: ' Regarding SOs, three were already adapting to living with their family member with an ABI, while the rest were awaiting their family member's discharge from a rehabilitation facility. SO01, SO02 and SO05 expressed challenges caring for someone who is no longer as independent as before. SO02 experienced additional struggles when it came to bathing her family member: 'I will go with him in the bath. I must get in the bath. I must sit by. I must give him the face cloth. It's like I'm teaching a 6-year-old to wash. I'm struggling because we don't know how long he is going to be like this [dependent].' (SO02, age 42, female) Unlike the other dyads, SO05 only expressed an increased role of driving her brother to appointments and for running errands as the major change: 'That's the only thing that has changed. I think I'm the chauffeurchauffeur.' (SO05, age 43, female) Four of the six individuals with ABI could not return to work post-discharge. These four participants understood the reasons for not returning to work and were willing to make necessary arrangements to ease into work settings as their recovery allowed. The other individual with ABI (P03) was a student who could not return to her undergraduate studies, and the last participant was on early retirement. As a result of her ABI, P03 was devastated that she could not return to her studies as planned:

Perspective on disability
Another concern among the SOs was that of stigma associated with ABIs. SO03 was comfortable sharing about the ABI with others whereas the individuals with ABI did not have similar feelings or attitudes:

Spiritual connection to recovery
Three individuals with ABI acknowledged and were grateful for their spirituality during their recovery. P04 boldly shared: 'But now God has given me a second chance and therefore I must rise for that… I have to fight for my wife and my kids,' and remained motivated throughout treatment as a result.
P03 commented on her "second chance" when discussing the severity of the car accident, 'I couldn't believe that I walked out of there alive. I got a second chance. I can't even compare myself to the person I was a few weeks ago.' Spirituality was tied into experiences that involved healing: 'After 24 hours, they were supposed to declare me dead. I got through the 24 hours to 33 days, and I woke up … My ancestors were with me.' (P02, age 47, male) P02 further offered advice to other individuals with ABI that involved trusting (higher power) and letting (this higher power) fight for you through the tribulations. It was evident that this participant found encouragement through spirituality.
Three of the six SOs shared their spiritual beliefs and the reliance on faith as integral in managing day-to-day challenges. SOs discussed how prayer helped them cope through the difficult period and the perceived premonition that warned them of something that was about to happen to their family member. SOs appeared to be thankful for their spirituality as it helped their family member with ABI through the healing process. SOs were aware of medical intervention surrounding the ABI, but still relied on their faith. The following attests to this: 'Even though they're [HCP] not sure whether he [family member with ABI] will be hundreds, but everything is going to be fine as we are hoping. All of us hope for the best. Only God provides.' (SO05, age 43, female)

Themes of participants with an acquired brain injury Healing takes time
Five of the six individuals with ABI were transferred to a rehabilitation facility after discharge from their respective acute hospital. They acknowledged the effects of their ABI as more serious than they expected and, consequently had extended hospital stays for rehabilitation: Along with the consequences of the ABIs, all participants were aware of the time factor that partnered with healing and the patience to regain independence. P06 shared about her progress: 'I know it might sound maybe cliché, but I think it's better to be positive, than to be negative. And the quicker that you get into it, to accept that you need help, you will do better Like in the start, I couldn't take a ball, just a small ball to put it from one bucket to another one. And now I'm using my toothbrush.' (P06, age 37, female) Two of the three individuals with ABI (P01 and P05) who were discharged at the time of their interview were attending outpatient therapy. P01's statement showed awareness of his additional therapy needs: 'I was going out of the hospital, and I heard I'm coming back every second week. Then I started realising that this [communication] is actually the main reasons.' (P01, age 56, male) Although P02 was not attending out-patient therapy, he continued to exercise at home to return to previous activities: 'I must not stay in one place. I must go up and down just a little bit in the house so that I must get used to those things [exercise] again.' (P02, age 47, male) An increased awareness of the individual with ABI's limitations appeared to be motivating and created a positive experience when noticing their own progress.

Perceptions of and need for support
All individuals with ABI expressed their emotions towards their injury were suppressed as they tried to cope and recover. While participants had differing opinions of how positive their hospitalisation was, they all expressed a need for specific support. The perception of their need for support may have been influenced by the context of the COVID-19 pandemic and changes in hospital staffing patterns during the time of crisis.
Participants perceived a need to have a space for therapeutic sharing. They might have had difficulties with the ABI itself, but the need that was expressed was one of sharing the experience that they have had, as is shown by P03: 'Everybody knows what I've been through, but nobody knows how I felt.' (P03, age 19, female) Two of the six ABI survivors expressed benefits of sharing thoughts and feelings with others who had also experienced such an injury. Services offered by social workers and psychologists were available to all individuals in this study, but only three made use of them. Participants suggested that acute and rehabilitation facilities consider creating environments for individuals with ABI to share experiences, such as support groups, which encourage emotional and psychological progress: 'I was talking to everybody and I was starting to feel better' (P01, age 56, male) 'They [The rehabilitation facility] should implement something where they can help people to be more positive about their situation' (P06, age 37, female) While some participants were positive about their encounters in the facility, others had negative experiences. Some participants raised complaints regarding service provision and readiness for discharge. Two individuals with ABI expressed that nursing staff were not proactive in looking after them during acute hospitalisation. Additionally, P04 was upset because he felt that he did not receive individualised care in the rehabilitation setting: 'So, some days they [physiotherapists] leave you for a moment to take care of another patient. I don't like that because I want them to finish with me before going on.' (P04, age 57, male) This participant voiced a misalignment in the support he received and what he felt he required. The feeling of frustration was evident as P04 became flustered discussing care within the facilities, losing grip of his cellphone, and requiring assistance from care workers during the videoconference.
Despite the expressed need for improved support, there was also a perception that their experience was mostly favourable. Three participants were still hospitalised in a rehabilitation unit, subsequent to discharge from an acute hospital, at the time of their interview and reported positive experiences regarding progress made. Two of the three participants felt adequately prepared to return home despite challenges they may still face: 'The therapists and the doctor are also giving me so much information. I feel better about all the anxiousness and … going home.' (P06, age 37, female) Participants acknowledged the impact of rehabilitation and took note of their own progress made during this time. Two participants shared their experiences: 'This place [rehabilitation facility] did wonders for me really.' (P03, age 19, female) 'My brain got better when I was here at Hospital H.' (P04, age 57, male)

Themes of significant others Information needs
Among all SOs, a clear need arose for streamlined services by HCP in the hospitals, as well as education and written information presented during the acute stage. As a result of poor coordination of services, there was limited guidance offered to SOs at the time of discharge: Another statement regarding realistic expectations was also made by SO03, 'Sometimes she gets aggressive, and I don't know why because they didn't even tell me you must expect something like this.' (SO03, age 47, female) Written information regarding various rehabilitation facilities and services would have been helpful in the case of SO01 where she suggested: 'I suggest brochures … because now everybody is phoning you with no concrete anything. I never took down anything over the phone. I told them, mail me, so I can read through it.' (SO01, age 42, female) It appears that participants preferred information in a written format, hard and/or electronic copies, to make informed choices. Information being provided verbally or telephonically may have contributed to the overwhelming emotions felt at the time of transfer from the hospital to rehabilitation facilities. The COVID-19 pandemic may have further contributed to this view as family members could not visit the hospital or rehabilitation facility and HCP may have relied on telephonic means of communication.
The importance of information to guide decision making was highlighted in the following statement: 'I did agree to anything they [HCP] were saying because I just assumed … they're professionals, they won't do something that was going to hurt him [family member with ABI]' (SO02, age 42, female) When the opportunity arose for the SOs to ask questions in the rehabilitation facilities, they felt informed and satisfied with what they were told. This opportunity only arose in the rehabilitation facilities when family meetings were held and not in the acute settings. Coping and advice to other significant others who are caring for an individual with an acquired brain injury All SOs offered advice or suggestions on how to cope when a family member has an ABI. SO06 and SO02 respectively stated the following which portrays positivity and a sense of embracing their new situation:

Discussion
The six main themes provide insight into the livedexperiences of a sample of individuals with ABI and their SOs one-month post-discharge from an acute facility. Their experiences were largely influenced by the COVID-19 pandemic. Improved communication with staff, the need for written information, a lack of physical contact with loved ones, a need for support groups as well as more streamlined services, were factors that shaped participants' experiences.
All individuals with an ABI expressed that emphasis was placed on making progress with physical abilities and minimal opportunities arose to work through their emotional trauma. Feedback within peer support groups may be beneficial for individuals with ABI to monitor their progress and emotional well-being (Reese et al. 2009). Support groups and psychosocial treatment can be encouraged in the early stages of care by allied HCPs (Nash et al. 2021;Wijekoon 2020). Not all participant experiences were negative. Participants additionally offered advice to other individuals with ABI in earlier stages of recovery, who may experience similar situations in the future. Sharing experiences and making sense of recovery between fellow survivors with an ABI may provide support in ways that are different to that of HCP and family members (Kersten et al. 2018;Wijekoon 2020).
A loss of an individual's idea of self, pre-injury, may alter how they perceive themselves within a familiar context, post-ABI, as they can no longer participate in tasks as actively or independently as before (Chembeni & Nkomo 2017).
Counselling is important and likely provides means for individuals with ABI and families to cope with stigma, loss and other emotional challenges post-ABI (Joosub 2019 Service provision, education and readiness for discharge were concerns raised by individuals with an ABI. Sufficient preparation and education around the time of discharge may ease anxiety and uncertainties felt post-discharge from acute hospitalisation (Abrahamson et al. 2017;Walker et al. 2021). Unfortunately, the transition between acute and rehabilitation facilities has been reported as fragmented in some instances (Piccenna et al. 2016). Healthcare teams could improve their handover by including a written report to HCP at the receiving facilities for improved continuity of care. This may allow for better understanding of the individual's current level of functioning and abilities transitioning from the acute hospital. Readiness for discharge can be determined by a team of collaborative professionals to ensure the best outcomes for the individual with an ABI and their family (Walker et al. 2021).
The two individuals with ABI who felt adequately prepared for discharge had improved insight into their ABI and were aware of ongoing rehabilitation needs. This reflects positively on patient education and person-centred care (Berntsen, Yaron, Chetty et al. 2021 (Akbar & Wissink 2018). An implication of this study would be for more companies to offer such benefits for individuals with ABI easing back into the work setting. Where this is not possible, psychosocial support and rehabilitation is re-emphasised (Whitehead & Baalbergen 2019). Neuropsychological difficulties in certain areas of functioning may influence the return to productive work and consistent neuropsychological assessment is highlighted (Fortune et al. 2021).
A loss of function in individuals with ABI may result in increased burden of care on the SOs (Bordonada 2017;Kreutzer 2018). In this study, all participants were fortunate to have the option of both in-and out-patient treatment, however this is not always the case for the general South African population (Joosub 2019). High-caseloads and time pressures, with few qualified allied HCP, could have led to disparities in access to care (Nash et al. 2021). SOs try to navigate changes in their loved ones as well as their own new roles and responsibilities. HCP can be a vital source of support to SOs at the beginning stages post-ABI, and throughout the rehabilitative process (Cheklin et al. 2020). Trained caregivers who offer additional psychosocial support have been regularly researched and encouraged in the literature (Karpa et al. 2020;Kreutzer 2018). One of the SOs caring for the individual with ABI at home felt encouraged and empowered by the preparation received from the step-down facility.
In this study SOs were willing to share their knowledge about ABIs to their communities, utilising the opportunity for education. Culture is likely an important factor that may influence how stigma is expressed and experienced by people living with disabilities and there is a need to move beyond traditional ideas to create awareness, but also encourage belonging within communities (Jansen-van Vuuren & Aldersey 2020). SOs expressed that being positive and embracing difficulties will help the family heal, as was found previously (Lond & Williamson 2019). On the contrary, the individuals with ABI were more self-conscious of their diagnosis and its implications. Increased self-awareness could be because of the stigma of an ABI (Villa et al. 2020). Access to helpful and accurate information about various diagnoses may be hindered because of misinformation, or cultural beliefs and practices (Villa et al. 2020). Future research studies could investigate spirituality and culture and the influence on individuals' attitudes to healing. Healthcare professionals such as SLTs, can address this need for education through peerbased support groups. Health literacy is important for families to better understand injuries and carry information into communities of any context (Li et al. 2020).
A finding of this study was the important role that the COVID-19 pandemic played in shaping individuals' experiences. The pandemic caused great upset despite the HCPs attempts of consoling patients and families, while adapting to the hospitals' changing protocols (Aquila et al. 2020). Emotional support and mental health of patients and HCPs were important during this time, but the need may not have been addressed, possibly influencing the quality of engagement between HCP, individuals with ABI and their families (O'Connell et al. 2021). Further research is warranted in this area.
The most prominent difficulty caused by the pandemic was cancellation of hospital visiting hours. This likely resulted in HCP filling familial roles, simultaneously attempting to maintain a professional boundary (Aquilia et al. 2020). Visiting hours provide an opportunity for HCP to give feedback to families, subsequently benefiting the individual with an ABI (Silvera, Wolf, Stanowski et al. 2021). By terminating face-to-face interactions, HCP most likely adjusted to using electronic communication (Boulton et al. 2021). This may have contributed to the negative experience regarding communication felt by SOs in this study.

Limitations of current study
Although this study consisted of a small sample of 12 individuals, it yielded clinically relevant findings that could be useful for HCP during the acute stage of recovery. Livedexperiences post-discharge have been widely explored, but there is limited research focusing on personal experiences onemonth post-discharge from acute hospitalisation in settings such as South Africa (Souchon et al. 2020;van Zyl et al. 2019).
An interpreter was not used for this study, narrowing the responses to include only English, which was none of the participants' first language. A longer time frame post-ABI may allow for more experiences to be shared. The first author only included individuals with ABI who had mild cognitivecommunicative difficulties, excluding experiences of individuals with moderate to severe ABI. To represent the diversity of the South African population, further large-scale studies in both public and private health sectors could be undertaken.

Conclusion
Effective communication, health education and handover between the healthcare team, individuals with ABI, and their SOs could improve individuals' overall experiences in the acute stages of recovery post ABI. As a result of subsequent emotional challenges, psychosocial intervention and support groups should be encouraged and made standard practice in acute and rehabilitation facilities (Panday et al. 2021).
Improved person-centred intervention and an established continuum of care may assist individuals with ABI and their families transition from hospital to their home environments (Whitehead & Baalbergen 2019). It may happen that individuals with ABI are discharged and unable to return for follow-up services (Joosub 2019). Clear professional communication, teamwork, and collaboration is paramount during the acute stage of care. The SLT and other HCP could therefore effectively use the time in hospital to ensure the most pertinent information is conveyed. Research on the use of therapeutic support groups and counselling techniques should be further explored within healthcare systems similar to that of South Africa such as Botswana and Namibia (Legatum Institute 2021).